TRPS and Migraine Romina Nassini*, Francesco De Cesaris, Pamela Pedretti and Pierangelo Geppetti
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The Open Drug Discovery Journal, 2010, 2, 55-63 55 Open Access TRPS and Migraine Romina Nassini*, Francesco De Cesaris, Pamela Pedretti and Pierangelo Geppetti Headache Center, University Hospital Careggi and Department of Preclinical and Clinical Pharmacology, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy Abstract: Migraine is a highly prevalent, disabling neurovascular disorder characterized by a combination of headache, nausea and altered sensory processing such as photophobia. Migraine has a strong genetic background but the molecular pathways that result in a migraine attack, and the role of various triggers, are poorly understood. The throbbing and pulsating pain associated with the headache phase of migraine attack implies an important role for the nociceptive activation of trigeminal intracranial afferents that contain calcitonin gene-related peptide (CGRP). Neurogenic inflammation triggered by the release of CGRP is now recognized as a significant underlying event in migraine. Indeed, CGRP receptor antagonists, the so-called “gepants”, have already proved effective in clinical trials as novel, migraine- specific drugs. An alternative therapeutic approach is the modulation of CGRP release. As potential targets, the transient receptor potential (TRP) channels expressed by a subpopulation of CGRP-containing nociceptive primary sensory neurons are gaining increasing prominence, principally because of the recent discovery of a variety of endogenous and exogenous TRP agonists known to induce migraine attack as well as their emerging role in neuropeptide release. The present review focuses on the potential role of the different TRP channels, especially TRPV1, in the migraine mechanism. Keywords: TRP channel, TRPV1, migraine, capsaicin, CGRP, neurogenic inflammation, clinical trials, heat, neuropeptides, geptins. INTRODUCTION the disorder. There is growing evidence that the initiating event (though influenced by several contributing factors such Migraine is a common, disabling and economically as stress, environmental agents or hormones) occurs in the costly [1, 2] neurovascular disorder that affects a significant central nervous system (CNS) and somehow involves portion of the population, an estimated 13 million trigeminal neurons [4, 7]. Americans. Underlying migraine are neurovascular events that result in the dilatation of blood vessels and subsequent In recent years, the hypothesis that the release of nerve activation and pain [3]. Disability due to migraine is calcitonin gene-related peptide (CGRP) from sensory severe. Although migraine involves patients from infancy neurons stimulates sensory nerve transmission and dilates through senescence, it is especially prevalent among women cranial blood vessels has gained experimental support [8], between the ages of 35 and 45 years, with one in five suggesting a major role of CGRP in the pathogenesis of individuals reporting one or more migraine headaches per migraine. In this perspective, CGRP receptor antagonists year in this age group. Migraine care is complicated by the have become attractive as potential migraine-specific drugs. fact that underlying triggers and pathways are poorly Moreover, it has been demonstrated that other brain regions understood. Genetic abnormalities may initiate the alteration with enriched CGRP receptor expression, such as the of the response threshold to migraine-specific triggers in the hypothalamus, are activated during spontaneous migraine brain, but the specific gene(s) involved have not yet been attacks [9]. The first experimental observations that CGRP determined [4]. The migraine attack can be precipitated by (8–37), a truncated form of CGRP [10], behaved as a an extraordinary variety of stimuli, including psychological competitive and selective antagonist of the biological effects stress factors, excessive ingestion of alcoholic beverages, of CGRP, including smooth muscle relaxation, were not menstrual cycle, and changes in barometric pressure, anti- pursued, mainly because of the short biological half-life of angina medicines, sleep deprivation, and other factors [5, 6]. this peptide. More recently, the inhibition of CGRP receptors The lack of knowledge about the pathways underlying with two chemically unrelated CGRP receptor antagonists, migraine attack is one of the major obstacles to the discovery telcagepant and olcegepant (collectively referred to as of better and safer drugs. Uncertainty also exists regarding “gepants”) [11, 12], has been successfully used to treat acute the precise site of action and molecular targets of the various migraine [13-15]. drugs used for both prophylaxis and symptomatic relief of CGRP is contained in neurons of the central and migraine attack. However, in recent years much progress has peripheral nervous system. In the periphery, except for been made to better understand the underlying mechanism of intrinsic neurons of the gastrointestinal tract, CGRP is strictly confined to a subpopulation of somatosensory neurons with cell bodies located in the dorsal root (DRG), *Address correspondence to this author at the Department of Preclinical and Clinical Pharmacology, University of Florence, Viale Pieraccini 6, 50139 vagal (VG) and trigeminal (TG) ganglia. The release of Florence, Italy; Tel: +39 055 427 1417; Fax: +39 055 427 1280; sensory neuropeptides, including CGRP, undergoes fine E-mail: [email protected] tuning by a series of mediators and agents that act at 1877-3818/10 2010 Bentham Open 56 The Open Drug Discovery Journal, 2010, Volume 2 Nassini et al. prejunctional receptors/channels on sensory nerve terminals. symptoms of migraine attack. A considerable number of A wide array of G protein-coupled receptors are involved in animal and human studies have been carried out to better this process, including those for bradykinin, prostanoids, understand the physiology and pharmacology of the sensory opioids, 5-hydroxytryptamine (5-HT1 receptor), histamine innervation of the dura mater and cranial vessels. Evidence (H3 receptor), neuropeptide Y, somatostatin, vasoactive obtained in experimental animals suggests that the migraine intestinal polypeptide (VIP), purines and galanin. One of the aura is the clinical manifestation of a cortical spreading major mechanisms that promotes CGRP release from depression (CSD) [24, 25]. It has been proposed that the sensory neurons is the activation of members of the transient neural changes caused by the slow depolarizing wave of receptor potential (TRP) family of channels, in particular CSD eventually result in the painful symptoms associated TRPV1 (Founding member of the Transient Receptor with vasodilatation of the cranial blood vessels and other Potential Vanilloid family). The present review focuses on phenomena of the migraine attack [4]. However, while the distribution and activation mechanisms of the different tonabersat, a drug specifically developed to block CSD, did TRP channels expressed by subsets of trigeminal primary abolish the aura, it failed to prevent the headache of migraine sensory neurons, and discusses the potential of this receptor attack, in either an acute or a chronic setting [26-28]. This family in migraine mechanisms. finding indicates that CSD and the resulting aura are epiphenomena, but not the cause of the pain of migraine PRIMARY SENSORY NEURONS AND NEUROGENIC attack. INFLAMMATION: ROLE IN MIGRAINE In experimental animals, particularly rodents, stimulation More than 70 years ago, Sir Thomas Lewis, in his of a subset of peptidergic somatosensory neurons leads to the pioneering studies [16], precisely defined the dual release of various neuropeptides, specifically CGRP and the 'nocifensor' role of a subset of primary sensory neurons. One tachykinins SP and neurokinin A (NKA). Activation of segment of the widely branching sensory fiber network of CGRP receptors and tachykinin (NK1, NK2 and NK3) this neuron responds to the injury and generates action receptors located on effector cells at the peripheral level potentials which are carried antidromically to collateral causes a series of inflammatory responses, collectively branches, where these branches release a chemical substance referred to as ‘neurogenic inflammation’ [17]. This term that causes a flare response and increases the sensitivity of refers to a cascade of events that occur mainly, but not other sensory fibers responsible for pain. It has been exclusively, at the perivascular level. Indeed, CGRP-, SP-, proposed that the neurons which mediate these responses and NKA-release induce vasodilatation in arterial vessels, belong to a previously unrecognized subgroup, and termed and plasma protein extravasation and leukocyte adhesion to ‘nocifensors’ because of their dual function. The first the vascular endothelium of postcapillary venules [17]. function of these nocifensors is to sense nociceptive/pain These two latter responses are mediated by NK1 receptor stimuli. The second is to promote a first line of defense, activation on endothelial cells, which results in a calcium- mediated through neurovascular responses, which includes dependent activation of intracellular contractile elements, arterial vasodilatation, plasma protein extravasation, and leading to the opening of gaps between cells and the other responses. All these responses are associated with the development of inflammatory edema. In the dura mater, capacity to release neuropeptides from peripheral terminals neurogenic plasma extravasation mediated by NK1 receptors of primary sensory neurons.